19 Mar Please compare and contrast two of the diagnoses discussed this week, and how each of them differs from malingering. Please answer in a minimum of 500 words and use?only
Please compare and contrast two of the diagnoses discussed this week, and how each of them differs from malingering.
Please answer in a minimum of 500 words and use only your textbook and notes/memory from the lecture to complete this assignment. Your word count should be included at the end of your writing. This assignment will not be accepted if it is in the form of a screen shot or jpeg file.
*make it simple
Somatic Symptom and Related Disorders
Chapter 8
But first..
Discussions and Reflections
Lots of great work, very insightful!
Midterm: Case Note
Extra Credit
Opportunities in Lecture, weekly
Module opening for Extra Credit in the next few weeks
Somatic: relating to the body, especially as distinct from the mind.
Somatic Symptom and Related Disorders
8.1. Clinical Presentation
8.2. Epidemiology
8.3. Comorbidity
8.4. Etiology
8.5. Treatment
8.6. Psychological Factors Affecting Other Medical Conditions
Malingering (not in the text)
Somatic Symptom and Related Disorders
Somatic Symptom Disorder
Illness Anxiety Disorder
Functional Neurological Symptom Disorder (Conversion Disorder)
Factitious Disorder
A Brief Overview
Psychological disorders that feature somatic symptoms are often challenging to diagnose due to the internalizing nature of the disorder, meaning there is no real way for a clinician to measure the somatic symptom.
Furthermore, the somatic symptoms could take on many forms
For example, the individual may be faking the physical symptoms, imagining the symptoms, exaggerating the symptoms, or they could be real and triggered by external factors such as stress or other psychological disorders. The symptoms also may be part of a real medical illness or disorder, and therefore, the symptoms should be treated medicinally.
A Brief Overview (Cont.)
All the disorders within this chapter share a common feature: there is a presence of somatic symptoms and/or illness anxiety associated with significant distress or impairment
Oftentimes, individuals with a somatic disorder will present to their primary care physician with their physical complaints
Occasionally, they will be referred to clinical psychologists after an extensive medical evaluation concludes that a medical diagnosis cannot explain their current symptoms
Despite their similarities, there are key features that distinguish the disorders in this class from one another
Clinical Presentation
8.1
Somatic Symptom Disorder
Individuals with somatic symptom disorder often present with multiple somatic symptoms at one time
These symptoms are significant enough to impact their daily functioning, such as preventing them from attending school, work, or family obligations
The symptoms can be localized (i.e., in one spot) or diffused (i.e., entire body), and can be specific or nonspecific (e.g., fatigue)
Individuals with somatic symptom disorder often report excessive thoughts, feelings, or behaviors surrounding their somatic symptoms (APA, 2022)
For example, individuals with somatic symptom disorder may spend an excessive amount of time or energy evaluating their symptoms, as well as the potential seriousness of their symptoms
A lack of medical explanation is not needed for a diagnosis of somatic symptom disorder, as it is assumed that the individual’s suffering is authentic
Somatic symptom disorder is often diagnosed when another medical condition is present, as these two diagnoses are not mutually exclusive
Somatic Symptom Disorder
Somatic symptom disorder patients generally present with significant worry about their illness
Their interpretation of symptoms is often viewed as threatening, harmful, or troublesome (APA, 2022)
Because of their negative appraisals, they fear that their medical status is more serious than it typically is, and high levels of distress are often reported
Oftentimes these patients will “shop” at different physician offices to confirm the seriousness of their symptoms.
Illness Anxiety Disorder
Illness anxiety disorder, previously known as hypochondriasis, involves an excessive preoccupation with having or acquiring a serious medical illness
The key distinction between illness anxiety disorder and somatic symptom disorder is that an individual with illness anxiety disorder does not typically present with any somatic symptoms
Occasionally an individual will present with a somatic symptom; however, the intensity of the symptom is mild and does not drive the anxiety
Acquiring a serious illness drives concerns and they will even avoid visiting a sick relative or friend for fear of jeopardizing their own health
Illness Anxiety Disorder (Cont.)
Individuals with illness anxiety disorder generally are cleared medically; however, some individuals are diagnosed with a medical illness
In this case, their anxiety surrounding the severity of their disorder is excessive or disproportionate to their actual medical diagnosis
While an individual’s concern for an illness may be due to a physical sign or sensation, most individual’s concerns are derived not from a physical complaint, but their actual anxiety related to a suspected medical disorder
This excessive worry often expands to general anxiety regarding one’s health and disease
Unfortunately, this anxiety does not decrease even after reassurance from a medical provider or negative test results, even when provided by multiple physicians and diagnostic tests
Illness Anxiety Disorder (Cont.)
As one can imagine, the preoccupation and anxiety associated with attaining a medical illness severely impacts daily functioning
The individual will often spend copious amounts of time scanning and analyzing their body for “clues” of potential ailments
Additionally, an excessive amount of time is often spent on internet searches related to symptoms and rare illnesses
Illness becomes a central feature of the person’s identity and self-image
Although extreme, some cases of invalidism have been reported due to illness anxiety disorder
Invalidism: Persistent false belief that, even after cure of a physical illness, one must continue to live as thought still afflicted.
Functional Neurological Symptom Disorder
Functional neurological symptom (conversion) disorder occurs when an individual presents with one or more symptoms of altered voluntary motor or sensory function (APA, 2022)
Common motor symptoms include weakness or paralysis, abnormal movements (e.g., tremors), and gait abnormalities (i.e., limping)
Sensory symptoms include altered, reduced, or absent skin sensation, vision, or hearing.
Less commonly seen are epileptic seizures and episodes of unresponsiveness resembling fainting or coma
The disorder was called “conversion disorder” in prior versions of the DSM and in the psychiatric literature.
“The term “conversion” originated in psychoanalytic theory, which proposes that unconscious psychic conflict is “converted” into physical symptoms” (APA, 2022)
Functional Neurological Symptom Disorder
The most challenging aspect of functional neurological symptom disorder is the complex relationship with a medical evaluation
While a diagnosis of conversion disorder requires that the symptoms not be explained by a neurological disease, just because a medical provider fails to provide evidence that it is not a specific medical disorder is not sufficient
Therefore, there must be evidence of an incompatibility of the medical disorder and the symptoms
For example, an individual experiencing a seizure would require a normal simultaneous electroencephalogram (EEG), indicating that there is not epileptic activity during what was previously thought of as an epileptic seizure.
Factitious Disorder
Factitious disorder differs from the three previously discussed somatic disorders in that there is deliberate falsification of medical or psychological symptoms imposed on oneself or on another, with the overall intention of deception
While a medical condition may be present, the severity of impairment related to the medical condition is more excessive due to the individual’s need to deceive those around them
Even more alarming is that this disorder is not only observed in the individual leading the deception— it can also be present in another individual, often a child or an individual with a compromised mental status who is not aware of the deception behind their illness
Factitious Disorder
Some examples of factitious disorder behaviors include, but are not limited to, altering a urine or blood test, falsifying medical records, ingesting a substance that would indicate abnormal laboratory results, physically injuring oneself, and inducing illness by injecting or ingesting a harmful substance
Although most individuals with factitious disorder seek treatment from health care professionals, some choose to mislead community members either in person or online about the illness or injury
While it is unclear why an individual would want to fake their own (or someone else’s) physical illness, there is some evidence suggesting that factors such as depression, lack of parental support during childhood, or an excessive need for social support may contribute to this disorder
Factitious Disorder (Cont.)
Individuals with factitious disorder are at risk for experiencing psychological distress or functional impairment causing harm to themselves and others such as family, friends, heath care professionals, and faith leaders.
The DSM-5-TR states, “Whereas some aspects of factitious disorders might represent criminal behavior, such criminal behavior and mental illness are not mutually exclusive” (APA, 2022, pg. 368).
Epidemiology
8.2
Somatic Disorders and Epidemiology
The prevalence rates for somatic disorders are often difficult to determine; however, overall estimates of somatic symptom disorder are around 4-6%
There is a trend that females report more somatic symptoms than males; thus, more females are diagnosed with somatic symptom disorder than males (APA, 2022)
Seeing as illness anxiety disorder is a newer diagnosis (replacing hypochondriasis), prevalence rates are largely based on the previous disorder
Previous findings suggest that illness anxiety disorder occurs in 1.3% to 10% of the general population and is equal among males and females
Somatic Disorders and Epidemiology (Cont)
Prevalence rates of factitious disorder are largely unknown, likely due to the use of deception in individuals diagnosed with the disorder
Additionally, health care professionals infrequently record the diagnosis, even in recognized cases (APA, 2022)
Like the other somatic symptom disorders, the prevalence of functional neurological symptom disorder is unknown, even though transient functional neurological symptoms are common
In the United States and northern Europe, research shows that the incidence of individual persistent functional neurological symptoms to be around 4-12 of every 100,000 annually (APA, 2022)
Comorbidity
8.3
Somatic Disorders and Comorbidity
Given that half of psychiatric patients also have an additional medical disorder, 35% have an undiagnosed medical condition, and approximately 20% reported medical problems caused their mental condition, it should not come as a surprise that somatic disorders, in general, have high comorbidity with other psychological disorders
More specifically, anxiety and depressive disorders are among the most commonly co-diagnosed disorders for somatic disorders.
While there is not a lot of information regarding specific comorbidities among somatic symptom and related disorders, there is some evidence to suggest hat those with illness anxiety disorder are at risk of developing OCD and personality disorders
Similarly, personality disorders are more common in individuals with functional neurological symptom disorder than the general public
Somatic symptom disorder is also comorbid with PTSD and OCD. (APA, 2022)
No comorbidity information is given for factitious disorder
Somatic Disorders and Comorbidity (Cont.)
There is also high comorbidity between somatic disorders and other physical disorders classified as central sensitivity syndromes (CSSs), due to their common central sensitization symptoms, yet medically unexplained symptoms (McGeary, Harzell, McGeary, & Gatchel, 2016)
Disorders included in this group are fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome
Comorbidity rates are estimated at 60% for these functional syndromes and somatic pain disorder (Egloff et al., 2014)
Etiology
8.4
Psychodynamic
Psychodynamic theory suggests that somatic symptoms present as a response against unconscious emotional issues
Two factors initiate and maintain somatic symptoms: primary gain and secondary gain
Primary gains produce internal motivators, whereas secondary gains produce external motivators
When you relate this to somatic disorders, the primary gain, according to psychodynamic theorists, provides protection from the anxiety or emotional symptoms and/or conflicts
This need for protection is expressed via a physical symptom such as pain, headache, etc.
The secondary gain, the external experiences from the physical symptoms that maintain these physical symptoms, can range from attention and sympathy to missed work, obtaining financial assistance, or psychiatric disability, to name a few
Cognitive
Cognitive theorists often believe that somatic disorders are a result of negative beliefs or exaggerated fears of physiological sensations
Individuals with somatic related disorders may have a heightened sensitivity to bodily sensations
This sensitivity, combined with their maladaptive thought patterns, may lead individuals to overanalyze and interpret their physiological symptoms in a negative light
For example, an individual with a headache may catastrophize the symptoms and believe that their headache is the direct result of a brain tumor, as opposed to stress or other inoculate reasons
When their medical provider does not confirm this diagnosis, the individual may then catastrophize even further, believing they have an extremely rare disorder that requires an evaluation from a specialist
Behavioral
Keeping true with the behavioral approach to psychological disorders, behaviorists propose that somatic disorders are developed and maintained by reinforcers
More specifically, individuals experiencing significant somatic symptoms are often rewarded by gaining attention from other people (Witthoft & Hiller, 2010)
These rewards may also extend to more significant factors, such as receiving disability payments.
While the behavioral theory of somatic disorders appears to be like the psychodynamic theory of secondary gains, there is a clear distinction between the two:
Behaviorists view these gains as the primary reason for the development and maintenance of the disorder
Psychodynamic theorists view these gains as secondary, only after the underlying conflicts create the disorder
Sociocultural
There are a couple of different ways that sociocultural factors contribute to somatic related disorders
First, there is the social factor of familial influence that likely plays a significant role in the attention to somatic symptoms
Individuals with somatic symptom disorder are more likely to have a family member or close friend who is overly attentive to their somatic symptoms or report high anxiety related to their health
Culturally, Western countries express less of a focus on somatic complaints compared to those in the Eastern part of the world
This may be explained by the different evaluations of the relationship between mind and body
For example, Westerners tend to have a view that psychological symptoms sometimes influence somatic symptoms, whereas Easterners focus more heavily on the mind-body relationship and how psychological and somatic symptoms interact with one another
These different cultural beliefs are routinely seen in research where Asian populations are more likely to report the physical symptoms related to stress than the cognitive or emotional problems that many in the United States report
Treatment
8.5
Treatment
Treatment for these disorders is often difficult as individuals see their problems as completely medical, and therefore, do not think psychological intervention is necessary
Once an individual does not find relief from their symptoms after meeting with several different physicians, they often do willingly engage in psychotherapy, psychopharmacology, or both
Among the most effective treatment approaches is the biopsychosocial model of treatment.
This approach considers the various biological, psychological, and social factors that influence the illness and presenting symptoms
This treatment is often achieved through a multidisciplinary approach where the symptoms are managed by many providers, usually including a physician, psychiatrist, and psychologist
The interdisciplinary approach involves a higher level of care as the multiple disciplines interact with one another and identify a treatment goal
This approach, although more difficult to find, particularly in more rural settings, is presumed to be more effective due to the integration of health care providers and their ability to work together to treat the patient uniformly
Psychotherapy: Psychodynamic
Interpersonal psychotherapy, a type of psychodynamic therapy, has been found to be efficacious in treating somatic disorders.
Interpersonal psychotherapy focuses on the relationship between self-experience and the unconscious, and how these factors contribute to body dysfunction
This type of treatment has been shown to reduce anxiety, depression, and improve the overall quality of life immediately following treatment; however, effects appear to diminish over time (Abass et al., 2014; Steinert et al., 2015)
Psychotherapy: CBT
Traditional cognitive-behavioral therapies (CBT) have been employed to address the cognitive attributions and maladaptive coping strategies that are responsible for the development and maintenance of the disorder
The most common misattribution for these disorders is catastrophic thinking, or the rumination about worst-case scenario outcomes
Additionally, goals of CBT treatment are the acceptance of the medical condition, addressing avoidance behaviors, and mediating expectations of treatment
Psychotherapy: Behavioral
Behavioral therapies have also been shown to effectively manage complex chronic somatic symptoms, particularly pain
The behavioral approach involves bringing attention to physiological symptoms, the individual’s attribution to those symptoms, and the subsequent anxiety produced by the negative attributions
Psychopharmacology
Psychopharmacological interventions are rarely used due to possible side effects and unknown efficacy
Given that these individuals already have a heightened reaction to their physiological symptoms, there is a high likelihood that the side effects of medication would produce more harm than help
With that said, psychopharmacological interventions may be helpful for those individuals who have comorbid psychological disorders such as depression or anxiety, which may negatively impact their ability to engage in psychotherapy (McGeary, Harzell, McGeary, & Gatchel, 2016)
Malingering
Not in the text
Malingering
The intentional fabrication or exaggeration of symptoms for secondary gain (e.g., time off work, avoiding the police, obtaining narcotics, insurance money, etc.)
Adoption of the sick role may provide the patient with an opportunity to avoid social obligations in a “socially accepted” way.
Complaints usually stop after the intended external reward has been obtained (as opposed to Factitious disorder)
Malingering individuals may be uncooperative and may insist on undergoing an extensive medical evaluation
Symptoms typically do not conform to a known medical or psychological condition
Symptoms are typically vague and inconsistent and/or false or significantly exaggerated
Malingering is not classified as a mental disorder
Malingering: Epidemiology & Management
Epidemiology
It occurs in males more often than females
Often occurs after an accident, particularly if legal proceedings are being started
Diagnostics
Any combination of the following is suggestive of malingering:
The patient presents under medicolegal circumstances (e.g., via self referral or referral by an attorney while criminal charges are pending).
Clinical findings are markedly inconsistent with the patient's complaints.
Lack of patient cooperation during diagnostic evaluation, follow-up, and/or treatment
Features of Antisocial Personality disorder
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Malingering: Management
Management
Explain the objective clinical and diagnostic study findings to the patient and make a detailed record in the patient's file.
Avoid unnecessary referrals, as this perpetuates the malingering
The diagnosis should only be directly discussed with the patient as part of a supportive confrontation.
Psychological Factors Affecting Other Medical Conditions
8.6
Psychological Factors
Although previously known as psychosomatic disorders, the DSM-5-TR has identified physical illnesses that are caused or exacerbated by biopsychosocial factors as psychological factors affecting other medical conditions.
This disorder is different than all the previously mentioned somatic related disorders as the primary focus of the disorder is not the mental disorder, but rather the physical disorder.
Psychological or behavioral factors adversely affect the medical condition by, “…influencing its course or treatment, by constituting an additional well- established health risk factor, or by influencing the underlying pathophysiology to precipitate or exacerbate symptoms or to necessitate medical attention” (APA, 2022, pg. 365).
It is believed that a lack of positive coping strategies, psychological distress, or maladaptive health behaviors exacerbate these physical symptoms (McGeary, Harzell, McGeary, & Gatchel, 2016).
Headaches
Among the most common types of headaches are migraines and tension headaches (Williamson, 1981).
Migraine headaches are often more severe and are explained by a throbbing pain localized to one side of the head, frequently accompanied by nausea, vomiting, sensitivity to light, and vertigo
It is believed that migraines are caused by the blood vessels in the brain narrowing, thus reducing the blood flow to various parts of the brain, followed by the same vessels later expanding, thus rapidly changing the blood flow. It is estimated that 23 million people in the U.S. alone suffer from migraines
Tension headaches are often described as a dull, constant ache localized to one part of the head or neck; however, it can co-occur in multiple places at one time
Unlike migraines, nausea, vomiting, and sensitivity to light do not often occur with tension headaches.
Tension headaches, as well as migraines, are believed to be primarily caused by stress as they are in response to sustained muscle contraction that is often exhibited by those under extreme stress or emotion
In efforts to reduce the frequency and intensity of both migraines and tension headaches, individuals have found relief in relaxation techniques, as well as the use of biofeedback training to help encourage the relaxation of muscles
Gastrointestinal
Among the two most common types of gastrointestinal psychophysiological disorders are ulcers and irritable bowel syndrome (IBS)
Ulcers, or painful sores in the stomach lining, occur when mucus from digestive juices are reduced, allowing digestive acids to burn a hole into the stomach lining.
Among the most common type of ulcers are peptic ulcers, which are caused by the bacteria H. pylori
While there is evidence to support the involvement of stress in the development of dyspeptic symptoms, the evidence linking stress and peptic ulcers is slowly growing
Researchers believe that while H. pylori must be present for a peptic ulcer to develop, increased stress levels may impact the amount of digestive acid present in the stomach lining, thus increasing the frequency and intensity of symptoms
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